COVID19 Parents

No Covid-19 vaccine for SA ‘any time soon’, as long as we keep having Loadshedding.

The chance of SA getting a significant volume of the vaccine in the next few months is “improbable”, said Wits University, professor of vaccinology Shabir Madhi. “The most highly optimistic projection is that we’d be fortunate to get any by the end of the second quarter next year.”The other problem is that the vaccine needs to be kept at -70°C, and SA has very few specialised facilities able to achieve such a low temperature. “You won’t be able to just pitch up at a pharmacy or clinic for a shot,” said Madhi. “To set up more storage facilities of that nature would take a huge amount of time and expense.


Lack of leading shedding over the past 10 months was NOT because of “ amazing ESKOM management, but because of a depressed economy and lack of demand for electricity47 % of small businesses closed their doors!Our hopes will be pinned on Aspen Pharmacare our homegrown South African mega pharmaceutical giant.In Africa, our greatest weapon is our age and our resilience and experience in fighting infectious diseases.So what are some of the reasons for Africa’s relatively low death rate?


So, right from the beginning, most African governments took drastic measures to try and slow the spread of the virus.


Average of an African is 19 years! Not COVID 19! that’s correct 19 years”We have in Africa] about 3% of the population aged over 65 years,” said Dr Matshidiso Moeti, the WHO Africa headOlder people in Africa more likely to live in rural areas away from the hot spots of infection.Furthermore, an underdeveloped transport system within and between countries appears to have been a blessing in disguise. It means that Africans do not travel as much as people do in more developed economies, minimising contact.


A study conducted by researchers at the University of Maryland in the US found a correlation between temperature, humidity and latitude, and the spread of Covid-19.There could be several reasons for this:

  • The relatively young population – more than 60% are under the age of 25
  • Experience in epidemic control from tackling other diseases
  • Cross-immunity from other coronaviruses
  • Low rates of travel and more outdoor living might also help.

This quote in the Washington Post 3 days ago:

South Africa’s second coronavirus wave is fueled by a new strain, teen ‘rage festivals.’

For the next 8 weeks, we all need to return to our vigilant behaviour of the first weeks of lockdown!


Why are there fewer cases of COVID in children?

Recent information published in a medical journal (American Society for Microbiology) a few days ago may indicate that the MMR( measles, mumps, rubella) vaccine is possibly protective in some way!

Antibody immunity to mumps has shown to reduced severity of COVID 19  in those under the age of 42 who have received MMR vaccination. A reported by Jeffery Gold, president of the World Organisation in Watkins, Georgia confirmed the research,  adding to other pieces of evidence showing that MMR vaccine may offer protection against COVID 19. Cape Town university has also conducted research and is beginning to show similar results. The study may explain why children have a much lower infection rate and a much lower death rate.

Most children get their first MMR vaccine at 12 months in South Africa and another dose around age six years.

MMR vaccine is not available to the vast majority of South Africans as it is not part of the Government vaccination schedule.

The main benefit of the MMR vaccine comes from the mumps portion of the vaccine and not the measles and rubella( German measles ). There is no separate vaccine for mumps, and immunity can only be acquired by receiving the MMR vaccine.

Mumps infection in South Africa predominantly occurs in spring affecting children under the age of 10 years, mainly between 5-9 years. Mumps is one of the most common causes of acquired nerve deafness!

With this information in mind, parents are advised to vaccine children at the age of 6 years, and 12 years. Based on the study, it would be prudent to vaccinate all those over the age of 40 regardless of the previous vaccinations.

The Mayo Clinic in the USA, a highly respected medical institution advises that:

Children should have MMR vaccine for the “first day of school.”

It’s vital to ensure that vaccinations are up to date.

Measles can cause serious complications such as pneumonia, encephalitis and leave you with chronic inflammation of your brain called “subsclerosing panencephalitis’. That can kill!

Mumps can; inflame the brain and cause meningitis, inflame the testes and ovaries causing infertility, and inflame the hearing nerve causing deafness.

Rubella or German measles can cause congenital disabilities. It’s a severe illness for pregnant mothers and newborn babies.

All of these viral infections are HIGHLY contagious. I have tried to illustrate the infectious nature of measles by comparing seasonal flu, COVID-19 and Measles, below.


What about the question of MMR and autism? What do parents need to know? Over the past 20 years as a paediatrician, I have answered may parents question on the connections of MMR and autism, and vaccines in general containing “lead” causing seizures and mental retardation in children.

The United Kingdom was impacted and ignored by the rest of the world.

The bottom line if you do not want to read further, there is NO credible connection and evidence that MMR and vaccines are causing severe medical or mental issues in children. Children should be vaccinated by a qualified medical professional with the knowledge to answer your questions, administer the vaccines safely, and treat any rare complication like allergic reactions. 

An excellent publication authored by Michael Fitzpatrick a UK doctor will reassure parents about the safety of MMR, and reassure parents of children with autism that they have not a reason to blame themselves over administering the vaccine to children.

John Flett


Cloth Face Coverings for Children During COVID-19

Cloth Face Coverings for Children During COVID-19

Cloth Face Coverings for Children During COVID-19

​​T​o protect ourselves and others from COVID-19, the CDC now recommends ​cloth face coverings be used when outside. But what about children? Read on for answers to some frequently asked questions about cloth face coverings and children during the COVID-19 pandemic.

Why are people wearing cloth face coverings right now?

Since so many people who have COVID-19 don’t have symptoms, wearing cloth face coverings reduces the chance of transmitting the virus through the spray of spit or respiratory droplets. This is especially true for when someone with COVID-19 comes within 6 feet of you, which is the range of transmitting infection through acts like sneezing or coughing.​​

Should children wear cloth face coverings?

Children under the age of 2 years should not wear cloth face coverings.

When do children need to wear cloth face coverings?

There are places where children should wear cloth face coverings. This includes places where they may not be able to avoid staying 6 feet away from others. For example, if you have to take them to the doctor, pharmacy, or grocery store.

However, there are other places where children do NOT need to wear a cloth face covering:

  • At home, assuming they have not been exposed to anyone with COVID-19.
  • Outside, as long as they can stay at least 6 feet away from others and can avoid touching surfaces. For example, it’s fine to take a walk as long as your children stay 6 feet away from others and do not touch tables, water fountains, playground equipment or other things that infected people might have touched.​

Caution: you may need to reconsider the use of cloth face coverings if:

  • The face coverings are a possible choking or strangulation hazards to your child.
  • Wearing the cloth face covering causes your child to touch their face more frequently than not wearing it.

Staying home and physical distancing is still the best way to protect your family from COVID-19. Especially for younger children who may not understand why they can’t run up toward other people or touch things they shouldn’t, it’s best to keep them home. Children who are sick (fever, cough, congestion, runny nos​e, diarrhea, or vomiting) should not leave home.

What if my child is scared of wearing a face covering?

It’s understandable that children may be afraid of cloth face coverings at first. Here are a few ideas to help make them seem less scary:

  • Look in the mirror with the face coverings on and talk about it.
  • Put a cloth face covering on a favorite stuffed animal.
  • Decorate them so they’re more personalized and fun.
  • Show your child pictures of other children wearing them.
  • Draw one on their favorite book character.
  • Practice wearing the face covering at home to help your child get used to it.

For children under 3, it’s best to answer their questions simply in language they understand. If they ask about why people are wearing cloth face coverings, explain that sometimes people wear them when they are sick, and when they are all better, they stop wearing them.

For children over 3, try focusing on germs. Explain that germs are special to your own body. Some germs and good and some are bad. The bad ones can make you sick. Since we can’t always tell which are good or bad, the cloth face coverings help make sure you keep those germs away from your own body.

One of the biggest challenges with having children wear cloth face coverings relates to them “feeling different” or stereotyping them as being sick. As more people wear these cloth face coverings, children will get used to them and not feel singled out or strange about wearing them.

What about children with special health care needs?

  • Children who are considered high-risk or severely immunocompromised are encouraged to wear an N95 mask for protection.
  • Families of children at higher risk are encouraged to use a standard surgical mask if they are sick to prevent the spread of illness to others.
  • Children with severe cognitive or respiratory impairments may have a hard time tolerating a cloth face covering. For these children, special precautions may be needed.

Is there a “right way” to wear a cloth face covering?

Yes. Place the cloth face covering securely over the nose and mouth and stretch it from ear to ear. Remember to wash your hands before and after you wear it and avoid touching it once it’s on your face. When back inside, avoid touching the front of the face covering by taking it off from behind. Cloth face coverings should not be worn when eating or drinking.

Wash cloth face coverings after each wearing.

What kind of cloth face covering is best?

Homemade or purchased cloth face coverings are fine for most people to wear. For children, the right fit is important. Pleated face coverings with elastic are likely to work best for kids. Adult cloth face coverings are usually 6×12 inches, and even a child-sized 5×10 inch covering may be too large for small children. Try to find the right size for your child’s face and be sure to adjust it for a secure fit.

Due to very limited supply now, professional grade masks like N-95 masks should be reserved for medical professionals on the front lines who have increased risk of exposure to coronavirus.

More Information:

Breast feeding

Deciding to breastfeed (The Basics)

 Deciding to breastfeed (The Basics)

Do doctors recommend breastfeeding?Yes. Doctors recommend breastfeeding your baby for at least 1 year (12 months) if possible. For the first 6 months, breast milk is the only food a baby needs. Most babies start eating other foods, in addition to breast milk, when they are 4 to 6 months old.

You might be unsure if breastfeeding is right for you, but it is the best choice for most mothers and babies. More and more women are making the choice to breastfeed because of its health benefits. Some women are concerned because they don’t have many family members or friends who have breastfed their babies. You might be thinking that it’s easier to use formula. Or maybe you are worried that you won’t be able to keep breastfeeding after going back to work. But there are usually ways to make breastfeeding work for you.

Breastfeeding has many benefits for both you and your baby. This is true even if you breastfeed for only a short time. Also, these benefits can last even after you stop breastfeeding. Aside from the health benefits, breastfeeding also helps you bond with your baby, which is very rewarding.

If you are thinking about breastfeeding, that’s great. This article will help answer some of the questions you might have.

What are the benefits for babies?In babies, breastfeeding can:

Help prevent stomach infections that can cause vomiting or diarrhea

Help prevent ear or lung infections

Help lower the risk of SIDS, which is when a baby younger than 1 year old dies suddenly for no known reason

Breastfeeding might also help babies gain weight at a healthy rate as they grow.

What are the benefits for mothers?Breastfeeding has benefits for the mother, too. Compared with women who feed their babies formula, women who breastfeed usually:

Have less bleeding from the uterus after giving birth

Have less stress

Lose more weight after pregnancy (if they breastfeed at least 6 months)

Don’t spend as much money to feed their baby

Don’t spend as much money on healthcare or miss as much work, because their babies get sick less often

Have a lower chance of getting breast, ovarian, or endometrial (uterine) cancer

How do the breasts make milk?Breast milk is made by the “milk glands” in the breasts (figure 1). During pregnancy, these glands get ready to make breast milk.

After you give birth, substances in your body called “hormones” cause your breasts to fill with milk. For the first few days after birth, you will make only a small amount of yellowish milk called “colostrum.” Colostrum has all of the nutrition a newborn needs. You will start making more breast milk a few days later, usually 2 to 3 days after giving birth.

Will I make enough milk?Most healthy women can make enough breast milk. Each time a baby feeds and empties the breasts, the body makes more milk. After a few weeks of breastfeeding, most healthy women make about 3 cups (or 24 ounces) of milk a day.

Certain things can cause you to have trouble making enough milk. This can happen if:

You don’t breastfeed often enough

Your baby has trouble getting milk during breastfeeding

You are tired, sick, or under a lot of stress

You take certain medicines

You smoke cigarettes

You have had certain types of breast surgery

If you have trouble making enough milk, or if you are having other problems with breastfeeding, talk with your doctor or nurse. You might also find it helpful to work with a breastfeeding expert called a “lactation consultant.”

When should I start breastfeeding?Most women should start breastfeeding in the delivery room. If possible, it helps to hold your baby right away after delivery. “Skin-to-skin contact” can help your baby learn to breastfeed. It’s best to start breastfeeding as soon as possible after giving birth, ideally within the first hour. During this time, most babies are awake and want to breastfeed.

If you can’t be with your baby right after birth, there are things you can do so that you can still breastfeed. You can use a device called a breast pump to collect breast milk for your baby to drink later. Using a breast pump also helps your breasts continue to make milk.

Can I breastfeed if I had breast surgery?Maybe. If you have had breast surgery, you can try to breastfeed and see if you make enough milk. Most women who had surgery to make their breasts bigger can make enough milk, but some can’t. Women who have had a breast reduction (surgery to make the breasts smaller) more often have trouble making enough milk. But it’s not the same for everyone.

When is breastfeeding not recommended?Doctors do not recommend breastfeeding if you:

Have an infection, such as HIV, that you could pass to your baby through breastfeeding. Ask your doctor if you are concerned about risk of infection.

Are getting treated for cancer.

Take certain medicines – Some medicines are not safe to take while you are breastfeeding. But in most cases, it’s possible to keep taking the medicines you need, or switch to different medicines. If you take any medicines, let your doctor or nurse know. He or she can make sure that those medicines are safe to take when breastfeeding.

Drink a lot of alcohol – When you drink alcohol, a small amount is passed to your baby through your breast milk. Doctors do not know exactly how much alcohol is “safe” to drink during breastfeeding, so they suggest avoiding or limiting it. If you do choose to drink, most doctors recommend having only an occasional drink that has the amount of alcohol found in 1 glass of wine. They also recommend waiting 2 hours after having a drink before you breastfeed.

Use certain drugs – Illegal drugs are harmful for a breastfeeding baby. Marijuana (along with other forms of cannabis) is legal in some places, but should be avoided if you are breastfeeding. There are studies that suggest it could cause problems in babies.

Also, doctors do not recommend breastfeeding for babies who are born with a medical condition called “galactosemia.” Talk to your doctor or nurse if you’re not sure if you should breastfeed.

Do I need to do anything or buy anything to get ready?Most women do not need to do anything or buy anything to get ready for breastfeeding. You might want to get a breast pump to use later, especially if you will be returning to work. This will allow you to pump milk for times when you need to be away from your baby.

What if I have questions about breastfeeding?If you have questions about breastfeeding, ask your doctor or nurse. You might also find it helpful to talk to a breastfeeding expert called a “lactation consultant.”


Learning disabilities (The Basics)

Patient education: Learning disabilities (The Basics)


What are learning disabilities?Learning disabilities are problems that cause a child to have trouble learning. For example, a child might have problems learning to read, write, or do math. Learning disabilities do not have anything to do with how smart a child is. Children with learning disabilities can be just as smart or smarter than other children their age. But they have brain differences that make it hard for them to learn, remember, and use information.

What are the symptoms of learning disabilities?The main symptom is not being able to learn as well as other children. For example, a child with a learning disability might not be able to read, write, or do math as well as other children who are the same age or in the same grade.

Will my child need tests?Yes. Your child will likely have a number of different tests. The tests check for any problems in the following areas:

IQ – IQ stands for “intelligence quotient.” This test measures how well a person solves problems and understands things.




Motor skills – These tests check how well a child can move large muscles (such as in the legs and arms) and small muscles (such as in the fingers).

The tests also include a review of the child’s school records and watching how he or she acts in a classroom. Different experts, including special education teachers, social workers, or guidance counselors, can do these tests.

A doctor, nurse, or other expert might also test your child for health or emotional problems, such as worrying or feeling sad or depressed. Problems in those areas can affect how well a child can learn.

How are learning disabilities treated?Learning disabilities are treated with “special education.” This is when a child learns from a teacher with special training. Special education uses different ways to teach children with disabilities. The methods depend on the learning disability. Examples include using pictures along with written or spoken words to explain things. Teachers might also give the child tips on how to remember things or help them stay organized. Children with learning disabilities might be given extra time to solve problems or take tests.

The earlier your child gets tested and treated for learning disabilities, the better he or she will do in school in the future.

Alternative medicine Parents

The End of Chiropractic

An article written by 3 chiropractors and a PhD in physical education and published on December 2, 2009 in the journal Chiropractic and Osteopathy may have sounded the death knell for chiropractic.

The chiropractic subluxation is the essential basis of chiropractic theory. A true subluxation is a partial dislocation: chiropractors originally believed bones were actually out of place. When x-rays proved this was not true, they were forced to re-define the chiropractic subluxation as “a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” Yet most chiropractors are still telling patients their spine is out of alignment and they are going to fix it. Early chiropractors believed that 100% of disease was caused by subluxation. Today most chiropractors still claim that subluxations cause interference with the nervous system, leading to suboptimal health and causing disease.

What’s the evidence? In the 114 years since chiropractic began, the existence of chiropractic subluxations has never been objectively demonstrated. They have never been shown to cause interference with the nervous system. They have never been shown to cause disease. Critics of chiropractic have been pointing this out for decades, but now chiropractors themselves have come to the same conclusion.

In “An epidemiological examination of the subluxation construct using Hill’s criteria of causation” Timothy A. Mirtz, Lon Morgan, Lawrence H. Wyatt, and Leon Greene analyze the peer-reviewed chiropractic literature in the light of Hill’s criteria, the most commonly used model for evaluating whether a suspected cause is a real cause. They ask whether the evidence shows that chiropractic subluxations cause interference with the nervous system and whether they cause disease. The evidence fails to fulfill even a single one of Hill’s nine criteria of causation. They conclude:

There is a significant lack of evidence in the literature to fulfill Hill’s criteria of causation as regards chiropractic subluxation. No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability. [emphasis added]

While some chiropractors have rejected the subluxation paradigm, it is supported by the major chiropractic organizations and schools and is considered essential by the great majority of practicing chiropractors. In two recent studies cited in the Mirtz et al. article, 98% of chiropractors believed that “most” or “many” diseases were caused by spinal misalignments and over 75% of chiropractors believed that subluxation was a significant contributing factor to 50% or more of visceral disorders (such as asthma and colic), an implausible idea that is not supported by any evidence whatsoever. Simon Singh was sued for saying so when he correctly referred to “wacky ideas” and “bogus treatments.”

When chiropractors use spinal manipulation therapy for symptomatic relief of mechanical low back pain, they are employing an evidence-based method also used by physical therapists, doctors of osteopathy, and others. When they do “chiropractic adjustments” to correct a “subluxation” for other conditions, especially for non-musculoskeletal conditions or “health maintenance,” they are employing a non-scientific belief system that is no longer viable.

As the authors of this paper indicate, the subluxation construct must go. And without the subluxation, the whole rationale for chiropractic collapses, leaving chiropractors no justifiable place in modern medical care except as competitors of physical therapists in providing treatment of certain musculoskeletal conditions.

The absence of publicity is astounding. This study has not even been noticed by the media. Where are the sensationalist journalists who usually exaggerate the news and make up provocative headlines? They could be trumpeting “Chiropractic Is Dead!” “Chiropractors Admit They Were Deluded by False Beliefs” “Simon Singh Vindicated: Chiropractic Really Is Bogus” and so on. Chiropractors demolishing the basis for chiropractic ought to be big news.

When the news finally gets out, I predict contorted efforts at damage control. Chiropractors will claim that it is not appropriate to apply the Hill criteria in this way, and that the criteria are not a valid test of causality. That’s a straw man: not even Hill suggested that the criteria were a definitive test. They are more of a guide to thinking about causality. Edzard Ernst, the world’s first professor of complementary and alternative medicine, finds them useful. He has recently applied Hill’s criteria to neck manipulation as a cause of stroke: he found that it fulfilled all but one of the criteria for causation. (Article pending publication). Chiropractors won’t like that either.

I predict the authors of this paper will be attacked as traitors by their colleagues. And I predict my own comments will be misinterpreted as some kind of personal vendetta and I will be called ugly names. I also predict that no one will dispassionately offer acceptable scientific evidence to contradict the findings of the paper (They can’t, because there isn’t any!). The first comment (and so far the only comment) on the Chiropractic and Osteopathy website offers no counter-evidence but rather calls for not letting evidence-based protocols overshadow clinical experience.(!) The Weekly Waluation of the Weasel Words of Woo could have a lot of fun translating that statement.

If chiropractors reject the conclusions of the Mirtz et al. paper, the burden of proof falls on them to show

  1.  that the subluxation can be objectively demonstrated,
  2.  that it does cause interference with the nervous system, and
  3.  that it does cause disease.

They have failed to do so for 114 years.

Most chiropractic research falls under the category of Tooth Fairy Science. Instead of doing good basic research to examine the subluxation construct as a falsifiable hypothesis, they blindly forged ahead, implemented it for diagnosis and treatment, and studied various aspects of its clinical use.

The chiropractic emperor has no clothes, and now even some chiropractors have realized that. This study should mark the beginning of the end for chiropractic, but it won’t. Superstition never dies, particularly when it is essential to livelihood.


Newborn chiropractic care Where is the evidence?

Newborn chiropractic care: Where is the evidence?

ABC Health & Wellbeing

To first-time parents, handling their newborn child is like holding a tiny creature made of the most delicate porcelain — but is also as floppy as a water balloon, and utterly helpless.

Key points

  • Chiropractors Association of Australia says three out of four randomised controlled trials of chiropractic treatment for colic in babies have shown benefits
  • Cochrane Collaboration review of six such trials has found studies were too small and of “insufficient quality”
  • RACP Paediatric Policy and Advocacy Committee chair says there is no evidence that newborns commonly have problems with spinal symmetry after a vaginal birth
  • RACP chair says parents considering treatment should ask about the risks

It is a slightly terrifying experience, until you get the hang of it.

So what then are we to make of the chiropractic treatment of newborns, which involves cracking their spine the way you might crack your knuckles?

Spinal realignment in young children is touted as a treatment for infantile conditions such as poor breastfeeding, colic and sleeping troubles.

An online video of such a treatment being applied to a four-day-old baby by Melbourne chiropractor Ian Rossborough (which has since been made private) drew a strong response in Australia and internationally earlier this year. It makes for uncomfortable viewing: there is a loud crack, as the chiropractor pushes his two fingers into the baby’s back.

The treatment was intended to resolve the baby’s persistent crying and colic, and in later statements the chiropractor said the treatment was successful.

Dr Rossborough has since had restrictions placed on his practice.

But is there any truth to claims the process of vaginal birth mean newborns commonly have problems with spinal symmetry that require treatment?

Paediatrician Dr Jacqueline Small said no.

“There’s no evidence that there’s misalignment of the spine in the way that the chiropractors claim there is,” Dr Small said.

A baby sustaining physical trauma during childbirth would not only be highly unusual and rare, but it would also call for management by an appropriate medical specialist, she said.

Dr Small, who is chair of the Royal Australian College of Physicians’ (RACP) Paediatric Policy and Advocacy Committee and a member of the college’s Paediatrics and Child Health Division Council, said in the vast majority of otherwise healthy babies, there was no evidence of misalignment of the spinal cord.

“And there’s no evidence that this is related to any of the symptoms they might experience,” she said.

Addressing ‘imbalances in spinal symmetry’

Manipulation of the spine is a mainstay of chiropractic therapy, according to the Chiropractors’ Association of Australia. Their website states that “the practice of chiropractic focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how this relationship affects the preservation and restoration of health”.

Chiropractors Association of Australia (CAA) spokesperson Dr Anthony Coxon said spinal realignment looked to address imbalances in spinal symmetry.

“These can cause changes in muscle tone that may over time have neurological effect, they may distort the posture, they may create muscle strains, and there is some suggestion that they may contribute to colic,” he said.

The CAA website cites a range of studies supporting the practice, but very few of these meet the so-called gold standard for clinical studies — the randomised controlled trial.

Such a trial design requires that participants are randomly allocated to a particular treatment or to a control treatment — usually either a placebo or an existing established treatment. Ideally, the participants themselves (or in this case their parents) are “blinded” to the treatment form used, so they do not know whether they have received the study treatment or the control treatment. This lessens the chance that any difference between the two treatments will be influenced by people’s expectations.

Review finds trials of insufficient quality

One 2012 study of chiropractic intervention in infants did take this approach. In it, 104 infants aged under eight weeks with unexplained persistent crying were randomised to one of three groups: manual therapy with a chiropractor in which the parents were aware of the treatment given; manual therapy in which the parents were not told of the treatment; and no therapy where the parents were also not told of the treatment given.

In all three groups, the parents completed a crying diary for the infant over the following ten days.

The study did report significant improvements in the treated infants compared to the untreated ones, regardless of whether the parents knew the treatment that was given.

Dr Coxon said of the four randomised controlled trials of chiropractic treatment for colic, three showed a benefit of treatment. So does this prove the case?

Not according to the Cochrane Collaboration, which publishes analyses that look at the sum total of studies in a particular situation and judges the overall state of play.

Its 2012 review of manipulative therapies for infantile colic, which included six randomised trials involving 325 infants, concluded that the studies were too small and of “insufficient quality” to draw confident conclusions.

Dr Coxon acknowledged there were gaps in the research when it came to chiropractic care of children, although he argued there were equally gaps in the research for mainstream medical interventions.

The other issue with treating something like colic was that it was a pretty non-specific, poorly understood condition, said Dr Small, pointing out that most colic goes away by itself over time.

“There might be any number of causes for a young baby crying, and for the vast majority, there’s no specific pathology and it will get better in time,” she said.

And the big risk with taking a colicky baby to a chiropractor was that a more serious, underlying problem could be missed, she said.

But Dr Coxon stressed that, just as a GP would refer a patient to a specialist if they felt they needed specialist treatment, so too would a chiropractor send a patient to a mainstream clinician if they felt it was warranted.

Controversy across all age groups

Spinal manipulation is controversial across all ages, because of the potential for harm. In adults, there is a risk of stroke and tearing in the inner lining of an artery in the neck and in children, there have been reports of bleeding in the brain and paraplegia.

Dr Small said there may be a risk that the spinal growth plates in newborns — the bits in between the vertebrae — might be damaged by spinal manipulation.

“Again, we don’t know how much evidence there is but it’s a theoretical possibility because there’s much more cartilage and quite delicate growth plates. So it is possible that [there] might be long term damage,” she said.

Recognising the more fragile nature of the newborn spine, Dr Coxon said the techniques applied to newborns, infants and children were very different to those used for adults.

“Best practice dictates that these techniques should be low velocity and low speed only when applied to very young children,” he said.

Ultimately, there is limited and generally poor quality evidence of the benefits of spinal manipulation on newborns — and clear evidence of the albeit small potential for major harm.

With this in mind, Dr Small said parents should ask about the risks of chiropractic treatments that are being suggested for their children.

“Even if they’re uncommon risks, if they’re severe risks where the child is otherwise healthy, then those serious risks take on a much greater significance,” she said.


Standard of care for children

Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children Committee on Pediatric Workforce
Scope of Practice Issues in the Delivery of Pediatric Health Care
ABSTRACT. In recent years, there has been an increase in the number of nonphysician pediatric clinicians and an expansion in their respective scopes of practice. This raises critical public policy and child health advocacy concerns. The American Academy of Pediatrics (AAP) believes that optimal pediatric health care depends on a team-based approach with coordination by a physician leader, preferably a pediatrician. The pediatrician is uniquely suited to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment, in all practice settings. The AAP recognizes the valuable contributions of nonphysician clinicians, including nurse practitioners and physician assistants, in delivering optimal pediatric care. The AAP also believes that nonphysician clinicians who provide health care services in underserved areas should be sup- ported by consulting pediatricians and other physicians using technologies including telemedicine. Pediatricians should serve as advocates for optimal pediatric care in state legislatures, public policy forums, and the media and should pursue opportunities to resolve scope of prac- tice conflicts outside state legislatures. The AAP affirms that as nonphysician clinicians seek to expand their scopes of practice as providers of pediatric care, stan- dards of education, training, examination, regulation, and patient care are needed to ensure patient safety and quality health care for all infants, children, adolescents, and young adults.
ABBREVIATIONS. AAP, American Academy of Pediatrics; CAM, complementary and alternative medicine; HPSA, Health Profes- sion Shortage Area; FOPE II, Future of Pediatric Education II.
This policy statement is intended to serve as an overarching document that will consolidate some of the concepts in existing American Academy of Pediatrics (AAP) policy on pediatric care provided by nonphysician clinicians and, thereby, replace previous AAP policy on the role of the nonphysician provider.1 AAP policy statements have generally addressed particular types of clini- cians, practice settings, or types of care and have not articulated a global AAP position on pediatric care delivered by nonphysician clinicians.1–13 The recom- mendations in this policy statement have been writ- ten to serve as an advocacy tool for the AAP as a whole as well as for individual chapters and mem-
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- emy of Pediatrics.
bers to use with legislators, policy makers, and other stakeholders in deliberations on nonphysician scope of practice issues. To the extent possible, the text of the policy statement, from which the recommenda- tions have been derived, proposes examples and strategies that address the practical aspects or imple- mentation of the recommendations.
In recent years, there has been a significant in- crease in the numbers and roles of nonphysician clinicians in the health care market. The AAP has monitored these trends in the delivery of care to pediatric patients by nonphysician clinicians, includ- ing but not limited to nurse practitioners, physician assistants, psychologists, pharmacists, massage ther- apists, physical therapists, occupational therapists, optometrists, acupuncturists, naturopaths, homeo- paths, and chiropractors.
Some nonphysician clinicians are seeking ex- panded scopes of practice, including the right to provide types of care traditionally reserved for phy- sicians. Nonphysician clinicians have succeeded in increasing their autonomy, scope of practice, pre- scriptive authority, and third-party reimbursement in most states. The AAP believes that as these non- physician clinicians expand their roles, high stan- dards of education, training, examination, regula- tion, and patient care must be adopted to protect patient safety and ensure effective quality health care for all infants, children, adolescents, and young adults.
The provision of optimal pediatric care depends on a team-based approach to health care with coor- dination by a physician leader, preferably a pediatri- cian. In the team-based model of pediatric care, the pediatrician, or when no pediatrician is available, the physician, assumes overall responsibility for the care of the patient. As leader of the pediatric health care team, the pediatrician oversees and coordinates the delivery of care, and when appropriate, delegates patient care responsibilities to nurse practitioners, physician assistants, and other nonphysician clini- cians within their legislated scopes of practice. This role includes supervising patient care delivered by
426 PEDIATRICS Vol. 111 No. 2 February 2003
Downloaded from by guest on March 1, 2019

nonphysicians. The pediatrician also determines when referral to a pediatric medical subspecialist, pediatric surgical specialist, or other physician is warranted. When patient care responsibilities must be shared by multiple providers, the pediatrician oversees the full range of health care services to ensure continuity of care within the child’s medical home. The team-based model of pediatric care seeks to provide high-quality, cost-effective care by mini- mizing duplication of clinical effort and promoting the appropriate and timely use of all health care providers on the team.
The efficacy of this team-based approach in im- proving patient outcomes is widely accepted by phy- sicians and nonphysician clinicians as well as the public. A variety of indicators, including an increas- ing pediatric population, the continuing specializa- tion of medicine, and improvements in access to care, have predicted an increased need and demand for pediatric health care services in the near future. To respond to these changes, it will be necessary for the physician leader to coordinate the care delivered by physicians, nurse practitioners, physician assistants, and other nonphysician clinicians who provide care to children. The AAP acknowledges the complexities and difficulties inherent in this role but believes that the pediatrician’s coordination of care is essential to ensuring the provision of optimal pediatric care.
The AAP believes that pediatricians are optimally suited to serve as leaders of the pediatric health care team because of their unique ability to manage, co- ordinate, and supervise the entire spectrum of pedi- atric care, from diagnosis through all stages of treat- ment, in all practice settings. As the clinician most extensively educated in pediatric health care, the pediatrician has a pivotal role in delivering optimal pediatric care and providing a “medical home” for patients. According to the medical home concept, the pediatrician possesses the clinical skills, medical knowledge, and other competencies necessary to provide accessible, continuous, comprehensive, fam- ily-centered, coordinated, compassionate, and cul- turally effective pediatric care, 24 hours a day, 7 days a week.2 Pediatricians are equipped to assess basic and complex health issues, involving areas as diver- gent as molecular genetics, toilet training, school problems, environmental health and safety, and the long-term care of children with chronic illness or disability. As part of this leadership role, the pedia- trician should serve as a consultant for other mem- bers of the team who also play an important role in the care of infants, children, adolescents, and young adults. The AAP believes it is ill advised, even in underserved areas, to create a system of care that allows for the independent practice of nonphysician clinicians. Such health care delivery could result in a 2-tiered system that would compromise the quality of health care that should be available to all pediatric patients.2 The role of the pediatrician consultant, therefore, is particularly important as a strategy to ensure the delivery of safe, competent, and appro-
priate pediatric care by providing support to non- physician clinicians who practice in underserved, rural, or otherwise remote areas.
The AAP likewise supports the concept that pedi- atricians, because of their broad base of knowledge and skills, must supervise the pediatric health care delivered by nonphysician clinicians using telemedi- cine and other technologies, when applicable, to as- sist in the delivery of pediatric health care. Accord- ing to Black’s Law Dictionary, to supervise means “to have general oversight over, to superintend or to inspect.”14 The AAP also believes that the pediatri- cian should participate in the training and educa- tional experiences of nonphysician clinicians to help ensure the competency of all team members. As an advocate for optimal pediatric care, the pediatrician should educate patients, their families, and their caregivers as well as policy makers about scope of practice issues and the use of complementary and alternative medicine (CAM).
Pediatric nurse practitioners and physician assis- tants frequently practice under the supervision of physicians. Table 1 illustrates the educational and practice differences among general pediatricians, pe- diatric subspecialists, pediatric nurse practitioners, and physician assistants.
Although studies highlight the ability of nurse practitioners and physician assistants to provide care comparable with that delivered by a physician (sometimes associated with a higher degree of pa- tient satisfaction), these studies are limited by their focus on short-term outcomes for isolated medical problems managed by health care professionals working in a supervised environment in which they have ready access to consultation.15–17 The ability of nonphysician clinicians to manage all levels and complexity of care independently has not been ad- dressed by such studies, and until well-controlled studies demonstrate comparable outcomes for care rendered by all such clinicians, the AAP opposes independent practice, independent prescriptive au- thority, and reimbursement parity for these nonphy- sician clinicians.
To ensure the health and safety of all children, a process must be in place through which the creden- tialing of all individuals claiming to be competent to care for children is systematically examined. Cur- rently, nurse practitioners and physician assistants must pass qualifying examinations developed by their certifying bodies; this is not the case, however, for all CAM practitioners. Consumers rely on gov- ernment agencies to ensure certain standards of care. Legislators must base their decisions on knowledge, not on testimonials by a limited number of satisfied individuals.
The AAP concurs with the position of the Ameri- can Academy of Physician Assistants that physician assistants should continue to practice medicine un- der the supervision of a physician, in recognition of the training and education of physician assistants and the importance of patient safety and strength of
AMERICAN ACADEMY OF PEDIATRICS 427 Downloaded from by guest on March 1, 2019

Downloaded from by guest on March 1, 2019
TABLE 1. Comparison of Pediatricians, Pediatric Nurse Practitioners, and Physician Assistants
General pediatricians
71 716*
Baccalaureate degree (approximately 4 y), medical school (4 y), residency (3 y)
Doctor of Medicine (MD) or Doctor of Osteopathy (DO)
American Board of Pediatrics American Board of
Independent practice
In all states
Pediatric subspecialists
13 407*
Baccalaureate degree (approximately 4 y), medical school (4 y), residency (3 y), fellowship (?2 y)
Doctor of Medicine (MD) or Doctor of Osteopathy (DO)
American Board of Pediatrics and other specialty boards for certain pediatric subspecialties
Independent practice
In all states
Pediatric nurse practitioners
Baccalaureate degree (approximately 4 y), 2 y of advanced education and supervised clinical training
Master’s degree minimum, doctoral degree in nursing (PhD, DScN) common
National Certification from Board of Pediatric Nurse Associates and Practitioners
Variation by state
Variation by state
Physician assistants
40 469§ (4% in general pediatrics and pediatric subspecialties)?
Physician assistant program comprises 2 y in classroom and 25–27 mo clinical training in primary care¶
2 y of college courses in basic science and behavioral science as prerequisites to physician assistant training. Baccalaureate degree not required§
Certification by the National Commission on the Certification of Physician Assistants
Direct physician supervision in all states
47 states plus District of Columbia and Guam§
No. of Certified Providers
No. of Accredited Training Programs
Length of Training
Educational Attainment
Certifying Body
Independent Practice or Supervision
Prescriptive Authority Accessed March 19, 2002. † Source: Accreditation Council for Graduate Medical Education. Available at: Accessed March 19, 2002.
* Source: American Board of Pediatrics. ABP workforce data main menu 2000. Available at:
‡ Source: Dunn AM. 1997 NAPNAP Membership Survey. J Pediatr Health Care. 1998;12:203–210.
§ Source: American Academy of Physician Assistants. Facts at a glance. Available at: Accessed March 19, 2002.
? Source: American Academy of Physician Assistants. Physician assistants in pediatrics. Available at: Accessed March 19, 2002. ¶ Source: American Academy of Physician Assistants. The physician-PA team. Available at: Accessed March 19, 2002.
Osteopathic Pediatrics
Regulated in all states plus District of Columbia and Guam§

the physician assistant-physician relationship.18 The AAP likewise opposes the independent practice of nurse practitioners, but endorses a collaborative and structured relationship, in keeping with their training and experience. Nurse practitioner educa- tion and training overlaps with and complements pediatric practice, and collaborative efforts serve to benefit child health.19 The AAP realizes that nurse practitioners, physician assistants, and other non- physician pediatric clinicians may care for children in underserved areas where patients have limited or no access to a physician. However, the AAP, which dedicates its efforts and resources to attaining the optimal physical, mental, and social health and well- being for all infants, children, adolescents, and young adults, does not support independent practice for nurse practitioners, physician assistants, and other nonphysician pediatric clinicians. The issue of patient access and underserved areas defies an easy solution. This problem may be related to maldistri- bution of pediatricians in some parts of the country. As of June 2002, there are 3216 primary medical Health Profession Shortage Areas (HPSAs), needing to provide care for 57 212 915 persons. The number of physicians currently based in these HPSAs can accommodate only 22 million of these patients (Rob- ert M. Politzer, ScD, Health Resources and Services Administration, written communication, August 14, 2002). Data suggest that the participation of midlevel practitioners in the health care of persons in under- served areas is less than anticipated, and that such practitioners relocate from underserved areas be- cause of quality of life issues and a desire to be closer to the amenities of urban centers.20
Because of these issues, the AAP recognizes the pressing need to provide support for nonphysician clinicians in rural, remote, or otherwise underserved areas by ensuring access to a pediatrician-consultant who has the education, skills, and expertise to ad- dress the entire spectrum of pediatric health care issues.
The AAP believes that telemedicine technologies will facilitate the pediatrician’s vital role as the leader of the pediatric health care team. The US Department of Health and Human Services defines telemedicine as the use of electronic communication and informa- tion technologies to provide or support clinical care at a distance.21 The Task Force on the Future of Pediatric Education II (FOPE II) affirmed that these technologies would allow the pediatrician to provide and support health care at a distance while monitor- ing and enhancing quality of care and improving communication with other members of the pediatric health care team.22 Because telemedicine will most likely reshape the relationships among physicians, patients, and other members of the multidisciplinary care team, the pediatrician is optimally suited to oversee and ensure the proper use of telemedicine in the global management of patient care from diagno- sis through all stages of treatment.
Recent technologic advances, such as the Internet,
the digitization of health care information, and wire- less technologies, have demonstrated the great po- tential to increase access to health care services by circumventing the distance between clinicians and consultants. Implementation of telemedicine technol- ogies, however, will require creative strategies to meet challenges in some areas of practice, such as appropriate criteria for supervision of nonphysician clinicians, reimbursement for telemedicine services, privacy of patient information, universal standards for telemedicine technologies, professional and med- ical liability, regulatory and jurisdictional issues re- lated to multistate licensure of clinicians, and high costs of transmission of medical information.
Solutions to address difficulties in implementing telemedicine technologies have already assumed many forms and have involved a range of stakehold- ers. Research is being conducted, for example, to measure the impact of telemedicine on government expenditure and third-party payers, patient and cli- nician satisfaction with telemedicine,23 and increased access to particular services through telemedicine. In California, Blue Cross is exploring the potential of telemedicine by establishing a statewide telemedi- cine network for its enrollees. To address high trans- mission costs, the Federal Communications Commis- sion established in 1997 the not-for-profit Universal Service Administration Company to provide a dis- count on telecommunication transmission charges to rural health care professionals. The Federal Commu- nications Commission has subsequently refined the Universal Service program to enhance and promote the provision of telemedicine services by eliminating limits on bandwidth and the number of services that can be supported by the program.21
In recent years, the role of CAM has also received increased attention. Controversy exists about the ef- ficacy of many of the modalities incorporated under the heading of CAM. Although many definitions exist,24 the National Center for Complementary and Alternative Medicine defines CAM as “those treat- ments and health care practices not taught widely in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance com- panies.” According to the National Center for Com- plementary and Alternative Medicine, “some ap- proaches are consistent with physiologic principles of Western medicine, while others constitute healing systems with a different origin. Although some ther- apies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine.”25
Although this policy statement will not address the treatments but rather the training of individuals who provide such treatments to children, it is impor- tant to note that little scientific evidence exists re- garding the safety and efficacy of CAM therapies in children. Indeed, there have been few randomized, controlled, double-blinded clinical trials on the use of CAM therapies in the pediatric population. Table 2 summarizes information on 5 of the most common practitioners of CAM.
AMERICAN ACADEMY OF PEDIATRICS 429 Downloaded from by guest on March 1, 2019

Summary of 5 Major Providers of CAM
Massage Therapy
No. of Providers
Approx 55 000– 70 000a
10 000 licensede
Approx 160 000– 220 000,h
approximately 40 000 Nationally Certified in Therapeutic Massage and Bodywork (NCBTMB)i
Approx 1500o
No. of Programs or Schools
16 accredited in the US by the Council on Chiropractic Education Commission on Accreditationb
34 accredited by the Accreditation Commission for Acupuncture and Oriental Medicinef
55 accredited in the US by the Commission on Massage Therapy Accreditationj
No current national standard for homeopathic education. 19 institutions are currently accredited or undergoing review for accreditation by the Council for Homeopathic Educationm
4 (3 US, 1 Canada) accredited by the Council on Naturopathic Medical Education. Another US program is a candidate for accreditationp
Length of Training
4 years chiropractic college (at least 4200 hours)b
Minimum 1725 hours, 1000 of which must be didactic, and 500 clinical, for NCCAOM certificationg
Usually minimum of 500 hoursk
Varies, but a minimum of 500 hours (or a combination of shorter training, apprenticeship, and clinical experience) is required for CHC certification.n
3 years of college ? 4 years of
naturopathic studyq
Content of Training
Years 1–2: biological and basic sciences, clinical disciplines. Years 3–4: supervised clinical training, often in college clinics
Acupuncture, herbal therapies
Massage therapy theory and technique, anatomy, physiology, business ethics, first aid, and CPR
Varies, but usually includes didactic and clinical components of classical homeopathy and basic sciences
Clinical nutrition, acupuncture, homeopathic medicine, botanical medicine, psychology, and counseling
Pediatric-Specific Training
120 hours leading to certification by the International Chiropractic Pediatric Associationc
NBCE indicates National Board of Chiropractic Examiners; NCCAOM, National Certification
Medicine; CPR, cardiopulmonary resuscitation.
a Source: American Chiropractic Association. Available at: Accessed March 19, 2002
b Source: Council on Chiropractic Education. Available at: Accessed March 19, 2002
c Source: International Chiropractic Pediatric Association. Available at: Accessed March 19, 2002
d Source: National Board of Chiropractic Examiners. Available at: Accessed March 19, 2002
e Source: Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA. 1998;280:788–794.
f Source: American Academy of Medical Acupuncture. Accredited and candidate programs of the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). Available at: Accessed March 19, 2002.
g Source: National Certification Commission for Acupuncture and Oriental Medicine. Available at: Accessed March 19, 2002.
h Source: American Massage Therapy Association. Massage therapy: key questions and answers. Available at: http://www.amtamassage. org/about/faq.htm. Accessed March 19, 2002.
i Source: National Certification Board in Therapeutic Massage and Body Work. Consumer’s guide to therapeutic massage and bodywork. Available at: Accessed March 19, 2002.
Downloaded from by guest on March 1, 2019
Commission for Acupuncture and Oriental

Educational Attainment
Doctor of Chiropractic (DC)
Varies, master’s degrees in acupuncture and doctoral degrees in oriental medicine (OMD)
No terminal educational degree, such as a doctorate
No terminal educational degree, such as a doctorate
Doctor of Naturopathy (ND)
Standardized Exams for Certification or Licensure
NBCE Certificate of Attainment awarded after passing exam Parts I, II. Exams consist of NBCE Parts I, II, III, Physiotherapy, Special Purposes Exam for Chiropractic (SPEC), Part IV Practical Examinationd
NCCAOM Certification in Acupuncture is basis for licensure. In some states, the NCCAOM certification in Chinese Herbology, as well as other qualifications, is also required. Diplomates use the designation DiplAc (NCCAOM)g
National certification exam qualifies diplomates to use the designation, NCTMB. In most of the 29 states, this exam is a basis for licensure. In the remaining states, a state exam is required.l
A variety of exams and certifications by professional associations exist, including the designation, Certified Classical Homeopath (CHC), granted by the Council for Homeopathic Certification. These are not, however, a basis for state licensuren
Naturopathic Physicians Licensing Exam
Certifying Body
National Board of Chiropractic Examiners
National Certification Commission for Acupuncture and Oriental Medicine
National Certification Board for Therapeutic Massage and Bodywork
Council for Homeopathic Certification, National Board of Homeopathic Examiners, American Board
of Homeotherapeutics
North American Board of
Naturopathic Examiners
Professional Associations
American Chiropractic Association, International Chiropractic Association, International Chiropractic Pediatric Association
American Association of Oriental Medicine, American Academy of Medical Acupuncture
American Massage Therapy Association
North American Society of Homeopaths, Homeopathic Academy of Naturopathic Physicians
American Association of Naturopathic Physicians
State Licensure Prescriptive
or Regulation
50 states, see No Federation of Chiropractic Licensing
39 states and No District of Columbiag
30 states and No District of Columbial
3 (homeopathic No license
contingent on holding current medical license in that state)n
11 states and No Puerto Ricoq
j Source: Commission on Massage Therapy Accreditation. Massage education institutions and programs. Available at: http://www. Accessed March 19, 2002.
k Source: American Massage Therapy Association. Starting a career in massage therapy: what you need to know. Available at: Accessed March 19, 2002.
l Source: American Massage Therapy Association. States with massage practice laws. Available at: lawstate.htm. Accessed March 19, 2002.
m Source: National Center for Homeopathy. Education directory. Available at: Accessed March 19, 2002.
n Source: Council for Homeopathic Education. Available at: Accessed March 19, 2002. o Source: The American Association of Naturopathic Physicians. About AANP. Available at: htm. Accessed March 19, 2002.
p Source: The American Association of Naturopathic Physicians. Accredited schools. Available at: education/accredited_schools.htm. Accessed March 19, 2002.
q Source: The American Association of Naturopathic Physicians. Frequently asked questions (FAQ). Available at: http://www. Accessed March 19, 2002.
AMERICAN ACADEMY OF PEDIATRICS 431 Downloaded from by guest on March 1, 2019

Children may receive care from CAM practitioners without it being revealed to their pediatrician. A 1997 study reported that the percentage of American adults using CAM increased from 34% in 1990 to 42% in 1997.26 The estimate for CAM use by the general pediatric population is lower, ranging from approximately 11% in 1994 to 20% in 1999.27,28 The rate for children with chronic or serious illness, how- ever, is much higher, varying according to age, back- ground, and access to services from 30% to more than 70%, according to 1998 data.29 These figures raise serious concerns. The pediatrician cannot be responsible for overseeing the actions of CAM pro- viders, but can take a proactive role in asking pa- tients and families about their use of CAM therapies. As advocates for their patients, pediatricians need to advise patients and their parents that the interactions between some CAM therapies and conventional medical treatments can cause complications and even death. Many people are unaware of this danger and view CAM therapies as natural and, therefore, safe, and so often do not report their use of CAM to their physicians.30,31 The AAP has recognized the importance of this issue and has published a series of recommendations on how to counsel families about CAM use for children with chronic illness or disabil- ity.24 The pediatric community has questioned the ability of CAM practitioners to identify serious or complex medical conditions that require referral to a physician for medical treatment.32 In addition, the opposition of some CAM practitioners to immuniza- tions negatively affects the health and safety of chil- dren in their care.
No uniform standards exist across the country for scope of pediatric practice of chiropractors, naturo- paths, and other CAM practitioners. As summarized in Table 2, pediatric training and experience are not specifically outlined or regulated. Studies document- ing improved outcomes and efficacy of treatments in pediatric practice for CAM practitioners do not exist. In view of this lack of national standards for pediat- ric care by CAM practitioners, the absence of studies documenting that the quality of health care for chil- dren provided by these practitioners is comparable with that provided by conventional clinicians, and the more extensive training and education of pedia- tricians, the AAP has concerns about the provision of health care services to pediatric patients by CAM practitioners.
The expansion of the scope of practice of nonphy- sicians, including CAM practitioners, has created new challenges for physicians in addressing profes- sional and medical liability issues in all specialties. Specific areas of risk for physicians supervising non- physician clinicians are improper delegation of au- thority, vicarious liability for medical care provided by nonphysician clinicians, and liability for nonmed- ical acts committed by nonphysician clinicians. When delegating authority to nonphysician clini- cians under their supervision, physicians should consider the legality of the delegation, the proper
method of delegation, and their oversight responsi- bilities for the delegated duties.
It may be necessary to remind legislators and health policy makers that a physician’s ability to delegate authority is governed by statutory and con- tractual limitations. Moreover, health care entities, such as hospitals or managed care organizations, may not authorize the delegation of more authority than is permitted by state laws, but they may impose limitations on the delegation of authority that are more restrictive than are state laws. These policies also may be admissible in a medical malpractice lawsuit as evidence of the standard of care. Physi- cians violating such policies may risk loss of employ- ment or revocation of privileges. Physicians and health care entities must, therefore, be knowledge- able about the terms of these statutes and should seek advice from a qualified attorney.
For nonphysician clinicians who choose to practice independently, there has to be exclusive professional responsibility for the care they provide and adequate malpractice insurance to allow appropriate financial remedy for adverse settlements or decisions. States that license nonphysician clinicians should, there- fore, require that they abide by the same rules re- garding malpractice insurance as do physicians. Be- cause physicians are held accountable for clinicians acting under their supervision, a pediatrician should obtain legal counsel to identify any potential profes- sional or medical liability issues before establishing a pediatric health care team, especially a team that includes CAM practitioners.
Because the integration of CAM with traditional medicine is relatively new, it follows that malpractice law involving CAM practitioners is relatively imma- ture. At this time, very little is known about malprac- tice risks of CAM for independent practitioners or for allopathic and osteopathic physicians using CAM along with conventional treatment. The literature contains some articles in which the theoretic liability for referrals to CAM practitioners is extrapolated from what is known about liability for referrals to traditional nonphysician clinicians.33–35 However, the appropriateness of this assumption is un- founded. The complexity of these and many other professional and medical liability issues demon- strates the need for pediatricians, as advocates for their patients, to educate legislators and health pol- icy makers about professional and medical liability issues and their implications for patient safety.
Scope of practice legislation falls under the juris- diction of individual states. State legislatures are, therefore, the loci of deliberations on these issues. Legislatures must evaluate the evidence and testi- mony of a variety of stakeholders, including physi- cians and nonphysician clinicians, when considering changes to scope of practice legislation. These com- peting political agendas and perspectives often gen- erate highly charged, polemical, and even acrimoni- ous debates that damage professional relationships between physicians and nonphysician clinicians.
Downloaded from by guest on March 1, 2019

Some states, however, have attempted to shift these deliberations from the state legislature to an alternative arena. The goal of this shift is to promote collegial relationships between physicians and non- physician clinicians that focus on serving the best interests of the public. For example, Texas has suc- ceeded in diffusing the political tensions of these debates since 1995 through its Ad Hoc Committee on Collaborative Practice. The committee comprises physicians and nonphysician clinicians, including nurse practitioners and physician assistants. In Tex- as’s legislative sessions of 1997, 1999, and 2001, the committee’s work obviated the need for scope of practice battles in the state legislature (A. Gilchrist, MD, Texas Medical Association, oral communica- tion, September 10, 2001). The AAP supports and encourages such nonlegislative forums to resolve scope of practice issues and commends efforts to promote collegial, productive relationships between physicians and nonphysician clinicians in the interest of optimal patient care.
When the resolution of scope of practice issues outside of the legislative arena is not possible, stake- holders with common positions on the issues should explore opportunities for collaboration. A number of strategies can be used to pursue legislative action. First, national medical and specialty societies can coordinate their efforts on nonphysician scope of practice issues when a nationally organized cam- paign is appropriate. Because most scope of practice conflicts occur at the state level, however, it is im- portant for AAP chapters, state medical societies, and other state-level entities to collaborate. In these efforts, state-level groups should make use of re- sources, particularly policy statements developed by national medical and specialty societies, for their advocacy activities at the state level. Such activities require physicians who are knowledgeable of law- making and policy-making processes and who have the skills necessary to be effective advocates in leg- islative deliberations. For this reason, AAP chapters should encourage, recruit, and train their members to serve as advocates of optimal pediatric health care in state-level policy initiatives on nonphysician scope of practice issues. This advocacy role should be ful- filled through active participation in policy debates conducted in state legislatures, the media, commu- nity-based programs, and other public forums.
In recent years, there has been an increase in the number of nonphysician clinicians in the health care market, as well as an increased interest in an expan- sion of their roles, including autonomy, prescriptive authority, and third-party reimbursement. Profes- sional and medical liability issues are also coming to the fore of the scope of practice debate. The educa- tion and evaluation of health care professionals is quite variable. Pediatricians are the most extensively educated providers of pediatric care. Nurse practi- tioners and physician assistants complete shorter but well-defined educational programs and examina- tions. Other clinicians may participate in only abbre- viated educational experiences in pediatric care.
Optimal pediatric care is best rendered using a team-based approach with a physician, preferably a pediatrician, as leader. The pediatrician can coordi- nate and direct patient care and assist nonphysician clinicians, even when these clinicians are practicing in rural or remote areas. The use of advanced tele- medicine technologies promotes quality health care for children who would otherwise be underserved by the current health care system. Communication between physicians and nonphysician clinicians is essential to ensure appropriate health care and min- imize the risk of harmful interactions between differ- ent medical treatments. Because legislation regard- ing scope of practice falls under the jurisdiction of individual states, pediatricians must be knowledge- able about law-making and policy-making processes and serve as advocates for quality health care for all infants, children, adolescents, and young adults.
The AAP affirms the following policy recommen- dations:
1. A physician, preferably a pediatrician, should serve as the leader of the pediatric health care team. This leadership role is based on the pedia- trician’s ability to manage, coordinate, and super- vise the entire spectrum of pediatric care, from diagnosis through all stages of treatment and in all practice settings. This role involves coordinat- ing and supervising the care provided by other pediatric clinicians, including care delivered via telemedicine technologies.
2. Pediatricians, as leaders of pediatric health care teams, must embrace their responsibility to edu- cate patients, their families, and their caregivers; health care purchasers; policy makers; the media; and the public about scope of practice issues and the appropriateness of different care options, in- cluding the use of CAM. Pediatricians should also participate, as appropriate, in the training and educational experiences of nonphysician clini- cians.
3. Comparable standards of scientific evidence should be applied to assess the outcome in all areas of clinical practice delivered by all providers of pediatric care.
4. Telemedicine technologies should be imple- mented as one means of improving the quality of pediatric care available to children who otherwise have limited access to health care. The safety, quality, and appropriateness of this care should be ensured by addressing professional and medi- cal liability issues and establishing technical stan- dards and guidelines and clinical practice proto- cols for pediatric care provided through telemedicine technologies.
5. Pediatricians should take a proactive role in ask- ing patients and families about their use of CAM therapies. Pediatricians cannot be responsible for overseeing the actions of CAM providers. Pedia- tricians can, however, advise patients and their families about the use of CAM and that interac- tions between some CAM therapies and conven- tional medical treatments can cause complications and even death.
AMERICAN ACADEMY OF PEDIATRICS 433 Downloaded from by guest on March 1, 2019

6. Nonphysician clinicians acting independently of physicians should be held to the equivalent de- gree of professional and medical liability as is a physician. States that license nonphysician clini- cians should, therefore, require that they abide by the same rules regarding malpractice insurance as do physicians. Because physicians are held ac- countable for clinicians acting under their super- vision, a pediatrician should obtain legal counsel to identify any potential professional and medical liability issues before establishing a pediatric health care team, especially a team that includes CAM practitioners.
7. To promote the highest standards of care in each state, scope of practice issues should be resolved through nonlegislative forums (like those on the model of the Texas Ad Hoc Committee on Collab- orative Practice), which include physicians and nonphysician clinicians, such as nurse practitio- ners and physician assistants. AAP chapters are encouraged to take a leadership role in establish- ing such forums in their respective states.
8. AAP chapters and state medical and specialty societies, as well as national medical and specialty societies, should be proactive in legislative advo- cacy and should partner in informing legislators, health care purchasers, the media, and the public about the differences in the education, skills, and knowledge of various health care professionals. Legislative advocacy includes opposing legisla- tion to expand the scope of practice of nonphysi- cian clinicians, particularly independent practice, independent prescriptive authority, and reim- bursement parity.
The Committee on Pediatric Workforce gratefully recognizes
the many stakeholders that contributed valuable perspectives and information during the development of this policy statement. In particular, the committee acknowledges the AAP chapters, com- mittees, sections, task forces, and other bodies that provided input during the Scope of Practice Open Forum at the 2001 National Conference and Exhibition. The Committee on Pediatric Work- force also thanks the American Academy of Physician Assistants, the National Association of Pediatric Nurse Associates and Prac- titioners, and the Texas Medical Association for their thoughtful and constructive comments on scope of practice issues.
Committee on Pediatric Workforce, 2002–2003
Carmelita V. Britton, MD, Chairperson Michael R. Anderson, MD
*Carol D. Berkowitz, MD
Aaron L. Friedman, MD
David C. Goodman, MD, MS Kristan M. Outwater, MD Richard J. D. Pan, MD, MPH Debra Ralston Sowell, MD
Gail A. McGuinness, MD American Board of Pediatrics
Past Committee Members and Liaisons
Frances J. Dunston, MD, MPH National Medical Association
Jeffrey J. Stoddard, MD Immediate Past Chairperson
Walter W. Tunnessen, MD American Board of Pediatrics
Jerold C. Woodhead, MD Past Committee Member
Ethan Alexander Jewett, MA *Lead author
1. American Academy of Pediatrics, Board of Directors. The role of the non-physician provider in the delivery of pediatric health care. AAP News. 1994;10:4. Available at: Accessed March 19, 2002
2. American Academy of Pediatrics, Medical Home Initiatives for Chil- dren with Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110:184–186. Available at: policy/s060016.html. Accessed September 26, 2002
3. American Academy of Pediatrics, Committee on Fetus and Newborn. Advanced practice in neonatal nursing. AAP News. 1992;8:7. Available at: Accessed March 19, 2002
4. American Academy of Pediatrics, Committee on Hospital Care. Medical staff appointment and delineation of pediatric privileges in hospitals. Pediatrics. 1996;98:983. Available at: re9640b.html. Accessed March 19, 2002
5. AmericanAcademyofPediatrics,CommitteeonHospitalCare.Therole of the nurse practitioner and physician assistant in the care of hospital- ized children. Pediatrics. 1999;103:1050–1052. Available at: http:// Accessed March 19, 2002
6. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. The role of the pediatrician in rural EMSC. Pediatrics. 1998; 101:941–943. Available at: Accessed March 19, 2002
7. American Academy of Pediatrics, Committee on Pediatric Workforce. Pediatric primary health care. AAP News. 1993;11:7. Available at: Accessed March 19, 2002
8. American Academy of Pediatrics, Committee on Pediatric Workforce. Pediatric workforce statement. Pediatrics. 1998;102:418 – 427. Available at: Accessed March 19, 2002
9. American Academy of Pediatrics, Committee on Practice and Ambula- tory Medicine and Committee on Fetus and Newborn. The role of the primary care pediatrician in the management of high-risk newborn infants. Pediatrics. 1996;98:789–788. Available at: policy/pe000786.html. Accessed March 19, 2002
10. American Academy of Pediatrics, Committee on School Health. Health appraisal guidelines for day camps and resident camps. Pediatrics. 2000; 105:643– 644. Available at: Accessed March 19, 2002
11. American Academy of Pediatrics, Committee on School Health. Role of the school nurse in providing school health services. Pediatrics. 2001; 108:1231–1232. Available at: Accessed March 19, 2002
12. American Academy of Pediatrics, Committee on School Health. School health assessments. Available at: re9862.html. Pediatrics. 2000;105:875–877. Accessed March 19, 2002
13. American Academy of Pediatrics, Committee on School Health. School health centers and other integrated school health services. Pediatrics. 2001;107:198 –201. Available at: re0030.html. Accessed March 19, 2002
14. Black HC, Nolan JR, Connolly MJ. Black’s Law Dictionary. 6th ed. St Paul, MN: West Group; 1990
15. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000;283:59–68
16. Karlowicz MG, McMurray JL. Comparison of neonatal nurse practitio- ners’ and pediatric residents’ care of extremely low-birth-weight in- fants. Arch Pediatr Adolesc Med. 2000;154:1123–1126
17. Hooker RS, McCaig LF. Use of physician assistants and nurse practi- tioners in primary care, 1995–1999. Health Aff (Millwood). 2001;20: 231–238
18. American Academy of Physician Assistants. Guidelines for ethical con- duct for the physician assistant profession. JAAPA. 2001;14:10–12, 15–16, 19–20. Available at: Accessed March 19, 2002
19. Murphy CE. Practice identity, collaboration, and optimal access to effective health care. J Pediatr Health Care. 2001;15:98–100
20. Medicare Payment Advisory Commission. Report to the Congress: Medi-
Downloaded from by guest on March 1, 2019

care Coverage of Nonphysician Practitioners. Washington, DC: Medicare
Payment Advisory Commission; June 2002
21. Office for the Advancement of Telehealth. 2001 Report to Congress on
Telemedicine. Rockville, MD: Office for the Advancement of Telehealth, Health Resources and Services Administration, US Department of Health and Human Services; 2001. Available at: http:// Accessed March 19, 2002
22. American Academy of Pediatrics, Task Force on the Future of Pediatric Education II (FOPE II). The Future of Pediatric Education II. Organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. A collaborative project of the pediatric community. Pediatrics. 2000;105(1 Pt 2):157–212
23. Pammer W, Haney M, Wood BM, et al. Use of telehealth technology to extend child protection team services. Pediatrics. 2001;108:584–590
24. American Academy of Pediatrics, Committee on Children With Disabil-
ities. Counseling families who choose complementary and alternative medicine for their child with chronic illness or disability. Pediatrics. 2001;107:598 – 601
25. National Center for Complementary and Alternative Medicine. What is CAM? NCCAM Web site. Available at: http://nccam. an/general/#whatcam. Accessed March 19, 2002
26. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 1998;280:1569–1575
27. Spigelblatt LS. Alternative medicine: should it be used by children?
Curr Probl Pediatr. 1995;25:180 –188
28. Gardiner P, Wornham W. Recent review of complementary and alter- native medicine used by adolescents. Curr Probl Pediatr. 2000;12:298 –302 29. Breuner CC, Barry PJ, Kemper KJ. Alternative medicine use by home-
less youth. Arch Pediatr Adolesc Med. 1998;152:1071–1075
30. Gulla J, Singer AJ. Use of alternative therapies among emergency de-
partment patients. Ann Emerg Med. 2000;35:226 –228
31. Berman BM, Swyers JP, Hartnoll SM, Singh BB, Bausell B. “The public
debate over alternative medicine: the importance of finding a middle
ground.” Altern Ther Health Med. 2000;6:98–101
32. Lee AC, Kemper KJ. Homeopathy and naturopathy: practice character-
istics and pediatric care. Arch Pediatr Adolesc Med. 2000;154:75–80
33. Dumoff A. Medical Malpractice Liability of Alternative/ Complementary Health Care Providers: A View from the Trenches. HealthWorld Online Web site. Available at:
public/legal-lg/medmalpr/dumoff.htm. Accessed March 19, 2002
34. Studdert DM, Eisenberg DM, Miller FH, Curto DA, Kaptchuk TJ, Bren- nan TA. Medical malpractice implications of alternative medicine.
JAMA. 1998;280:1610–1615
35. Studdert DM. Legal issues in the delivery of alternative medicine. J Am
Med Womens Assoc. 1999;54:173–176
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
AMERICAN ACADEMY OF PEDIATRICS 435 Downloaded from by guest on March 1, 2019

Scope of Practice Issues in the Delivery of Pediatric Health Care
Committee on Pediatric Workforce Pediatrics 2003;111;426 DOI: 10.1542/peds.111.2.426
Updated Information & Services
Subspecialty Collections
Permissions & Licensing
including high resolution figures, can be found at:
This article cites 30 articles, 15 of which you can access for free at:
This article, along with others on similar topics, appears in the following collection(s):
Administration/Practice Management _management_sub
Quality Improvement sub
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at:
Information about ordering reprints can be found online:
Downloaded from by guest on March 1, 2019

Scope of Practice Issues in the Delivery of Pediatric Health Care
Committee on Pediatric Workforce Pediatrics 2003;111;426 DOI: 10.1542/peds.111.2.426
The online version of this article, along with updated information and services, is located on the World Wide Web at:
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2003 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
Downloaded from by guest on March 1, 2019

Alternative medicine

Don’t take your child to a Chiro warns a top Doctor

Don’t Take Your Baby To The Chiropractor, Top Doctor Warns Parents

Canada’s chiropractors say there are health benefits.

A chiropractor adjusts a one-month-old baby.

A chiropractor adjusts a one-month-old baby.

Thinking of taking your baby to have their spine adjusted by a chiropractor?

Don’t do it, warns the Australian Medical Association.

In a popular parenting page, Australian Medical Association (AMA) Northern Territories President Dr. Robert Parker urged parents to always see a doctor for any health concerns with their children, according to NT News. Babies and young children can’t communicate about their pain easily, and any potential complications could be quite serious, NT News reported Parker as saying (it appears his comments have seen since been deleted from the Facebook post).

“The AMA doesn’t support babies going to the chiropractor at all,” Parker said in response to a mom’s post seeking chiropractor recommendations for her 17-month-old, according to NT News.

“The AMA would be opposed to any unusual spinal manipulation in babies. We certainly would have some significant concerns about chiropractors and young children.”

The medical community has voiced its concerns before


It’s not the first time the AMA has warned parents to avoid the chiropractor. In 2013, AMA President Dr. Steve Hambleton outlined his concerns in an interview with ABC Radio 612, saying there wasn’t sufficient evidence to recommend chiropractic care for children.

“Unless there’s scientific evidence for any complementary therapies — we can’t recommend that they go there, and that includes chiropractory,” Hambleton said, according to a transcript posted to the AMA website.

And in 2016, the president of the Royal Australian College of General Practitioners lambasted the entire chiropractic industry after a controversial video emerged of an Australian chiropractor manipulating the spine of a newborn. Dr. Frank Jones told that the treatment was “outlandish,” and that there’s “no scientific basis for most of the stuff they do.”

Canada’s chiropractors say there are health benefits


Pediatric care is within the regulated chiropractic scope of practice and is overseen by provincial ministries of health, the Canadian Chiropractic Association (CCA) said in a statement emailed to HuffPost Canada.

“Chiropractors treat children of all ages every day across Canada and many times they are referred from another health care provider,” the CCA said.

Treatment for children and infants is modified for their smaller frames, they noted, and it “frequently involves gentle touch and spinal massage, stretching, exercises, soft tissue therapy, and postural counselling.” Chiropractors require informed consent from a parent or legal guardian before initiating a clinical encounter with a child, they added.

“Children and youth may benefit from chiropractic care just like adults,” the CCA said.

“They can suffer from back pain and other spine, joint and muscle problems because of sitting posture at their computers, heavy backpacks, sports, and frequent tumbles and falls,” the CCA said.

Chiropractors will refer children to physicians if a diagnosis doesn’t indicate chiropractic care is required, or if other interventions are needed, the CCA wrote on its website.

Canada’s pediatricians urge open and honest discussions with parents


In a position statement that was reaffirmed in 2016, the Canadian Paediatric Society (CPS) urged its doctors to have open and honest conversations with parents using or considering chiropractic care in the hopes that they will choose to do so rationally “in selected musculoskeletal conditions for which there is proof of efficacy.”

Many families will not spontaneously disclose that they’ve decided to take their child to a chiropractor, CPS said, potentially because they expect a negative reaction. But it’s important for a physician to know about any alternative treatments being given to a child, especially given that some chiropractors may give advice related to immunizations, they explained.

“The physician should routinely ask families about complementary and alternative therapies or products that their child may be using. When the parents disclose that they have been taking the child to a chiropractor, one should inquire whether neck manipulations or forceful thrusts have been used, and if herbal or homeopathic preparations have been given,” CPS wrote in the position statement.

“All questions arising about the risks and benefits of immunization must always be discussed. If it is established that a chiropractor has negatively influenced a decision, it can then be pointed out that the CCA accepts and endorses vaccination.”

CPS concluded that well-designed studies are needed to evaluate whether chiropractic care is effective for children.

Gastro osophageal reflux

Infant Gastroesophageal Reflux and Chiropractors

Separating Fact from Fiction in Pediatric Medicine: Infant Gastroesophageal Reflux

By now, regular SBM readers should be aware of the Choosing Wiselyinitiative. Just in case, Choosing Wisely is a campaign developed by the ABIM Foundation to bring together experts from a variety of medical specialties in order to identify common practices that should be questioned by patients and providers, if not outright discontinued. Their ultimate goal was not to establish treatment guidelines or dictate care, but to foster discussion. As I’ve written about in a prior post on the overuse of antibioticsin pediatrics, it doesn’t appear to have caught on. I routinely ask colleagues, residents and students if they are aware of it, and am frequently disappointed by their response.

The American Academy of Pediatrics issued a list of five questionable practices back in February of 2013 and I loved it. All five are important:

    1. Stop treating viruses with antibiotics
    2. Stop prescribing and recommending cough and cold medicines for young children
    3. Stop routine use of CT scans for minor head injuries
    4. Stop routine use of neuroimaging for simple febrile seizures
    5. Stop routine use of CT scans for abdominal pain

While reviewing current evidence-based guidelines on managing gastroesophageal reflux in children for this post, I was surprised to find that in March of this year the AAP had released an additional five questionable practices for Choosing Wisely:

  1. Stop high-dose steroids for the prevention or treatment of bronchopulmonary dysplasia in preterm infants
  2. Stop blindly ordering food allergy screening panels without taking medical history into account
  3. Stop prescribing acid blockers and motility agents for physiologic reflux
  4. Stop surveillance cultures for screening and treatment of asymptomatic bacteriuria
  5. Stop routine use of infant home apnea monitors to prevent SIDS

Naturally, I took number 8 as a sign that I was on the right track.

The problem of gastroesophageal reflux comes up frequently in pediatric medicine, especially during the first few months of a child’s life. Early in our residency training we learn about the existence of the so-called “happy spitter”, the baby who spits up for no apparent reason and without apparent symptoms. We learn to educate worried parents about this phenomenon, jokingly pointing out how this is usually a laundry problem rather than a medical problem. We are taught the signs and symptoms of gastroesophageal reflux disease (GERD) in children of varying ages, the behavioral modifications that might ameliorate the condition and the potential pharmacological and surgical interventions sometimes necessary in severe cases. While reflux is extremely common in babies, GERD is not.

But, as is often the case, something goes wrong after residency. Too many of us begin to alter our approach because of the influence of practicing in the real world and of common hardwired errors in how we interpret reality. Overuse of prescription medications, unnecessary formula hopping and potentially unsafe recommendations on sleep positioning are unfortunately widespread. Our pharmaceutical interventions carry significant risk with little evidence of benefit for most patients, and the combination of stress and a general lack of understanding of the pathophysiology of reflux leads to many parents seeking alternative treatments. Practitioners of irregular medicine are of course more than happy to claim expertise and success in treating what is largely a self-limited condition.

What is gastroesophageal reflux?

Gastroesophageal reflux, henceforth referred to simply as reflux, occurs when stomach contents pass into the esophagus. It is incredibly common in early infancy but occurs throughout the lifespan and is considered a normal aspect of our physiology. It is arguable that 100% of young infants have multiple episodes of reflux daily, with many being clinically silent because the stomach contents only ascend partially up the esophagus and are quickly cleared. Even when the bolus ascends to the oral cavity, infants often simply swallow it back down and caregivers are none the wiser.

But virtually 100% of children will have at least one episode of actual regurgitation (“spitting up”) at some point in early infancy, with most having several. Half of infants under 3 months of age will have a daily episode of regurgitation, and by 4 months of age, which tends to be the peak of incidence and severity, this will occur in two thirds. Incidence drops off steadily after 4 months, with only 5% of infants having daily regurgitation at one year of life. It is very uncommon for children over 18 months of age to still regurgitate, and even less so for them to start spitting up after that age.

Although in most children reflux is an uncomplicated and physiologic (normal) process, there are a variety of disease states and anatomical abnormalities that promote reflux or cause symptoms which might be confused for it. It is always very important for a child’s pediatrician or family doctor to evaluate them for any red flags such as bile-stained or bloody vomit, or vomiting that is consistently forceful in nature. Many neurologic conditions and systemic illnesses can result in either pathologic vomiting or increase the likelihood of severe symptomatic reflux in children of all ages.

Why is reflux so common in babies?

A convergence of physiology and anatomy occurs at the distal end of the esophagus which acts to limit retrograde movement of stomach contents. When not swallowing, the muscular tissue of the esophagus at the entry point into the stomach tends to remain contracted. This entry point occurs just beneath the diaphragm in most individuals, the pressure from which adds to the increased resting tone of the esophageal muscle. The angle of entry of the esophagus into the stomach is rather acute as well, leading to it being squeezed shut by a distended stomach.

In healthy people of all ages, but particularly infants, the normal high resting tone of the lower esophageal sphincter relaxes for no apparent reason during the time between feeds. This can occur upwards of 30 times each day in a young infant, likely because of general immaturity of many such processes. Older children and adults have the benefit of gravity when these events occur. When upright, all that tends to escape is gas in the form of a burp. But an infant is supine for significant periods of time and the entry point of the esophagus into the stomach is frequently covered with liquid breast milk or formula.

Young infants consume their entire caloric intake in the form of liquid, often taking in as much as 180 milliliters per kilogram each day. For a 75 kg adult that would equal just under 14 liters of fluid. And young infants feed much more frequently than older children and adults, so their stomachs are very full much of the day. Try drinking a couple of liters of milk every 3-4 hours. This extreme gastric distention increases the likelihood of transient relaxation events. Add to all this the fact that the angle of esophageal entry into the stomach is more obtuse than in older kids and adults, which is why distention of the stomach doesn’t squeeze it shut as effectively.

What is physiologic reflux, and more importantly, what isn’t it?

Physiologic reflux, even when the episodes of regurgitation are frequent, doesn’t result in weight loss or significant difficulty with feeds. The episodes of spitting up are typically not associated with crying or unusual movements, and there usually are not any red flags for a more concerning disease process. Reassurance really is the best approach as this almost always resolves on its own within a few months.

But parents will sometimes report that their otherwise “happy spitter” with physiologic reflux has difficulty sleeping or persistent nasal congestion. More common are complaints of general fussiness or irritability which have already been attributed to reflux in the minds of the caregivers. These symptoms, however, are very unlikely to be related to reflux, a revelation that I find most parents and often other medical professionals have great difficulty accepting.

As you can probably imagine with such subjective concerns, there are many different potential causes of apparent discomfort in an infant ranging from the benign to the life-threatening. And as with infant colic, psychosocial factors must always be taken into account since they can alter parental perception of reality and exacerbate, if not cause entirely, the subjective symptoms being attributed to reflux in a baby. With colic, how long and how severe the episodes of crying truly are is often warped by parental stress and sleep deprivation. How many times each day that a baby regurgitates, and the degree of fussiness during or between those episodes, is no different. Few parents are going to keep a detailed reflux diary.

There really is little in the way of solid evidence linking reflux to pain in the overwhelming majority of babies. Parents and physicians have historically made assumptions based on adult data and “experience”, but a review of the literature reveals a different story. Most studies have not supported the connection, even those that evaluate infants using monitoring of esophageal pH. And the best placebo-controlled studies have found that medications which decrease the production of gastric acid have no better impact than placebo on parental perception of infant irritability.

There are conservative and low risk behavioral and dietary interventions that can be recommended when reassurance fails or when parental quality of life is significantly affected. Unfortunately, these are often only discussed in the mildest cases of reflux. And prescription medications are far too quickly recommended despite a lack of evidence of efficacy, hence their inclusion on the AAP Choosing Wisely list.

The vast majority of episodes of reflux are very brief, and even if there is a significant acid component it is quickly cleared by the esophagus. And a layer of mucous is typically present which protects the esophageal lining from any injury. These normal protective mechanisms can be overwhelmed, particularly in children with neurological and anatomical risk factors, but significant symptoms related to reflux can occur, although uncommonly, even in otherwise-healthy babies leading to a diagnosis of GERD.

What is gastroesophageal reflux disease?

True GERD can present in a variety of ways depending on the age of the child, but is notoriously difficult to diagnose with any real certainty in a baby. An infant, for instance, doesn’t have the capacity to describe their heartburn. In babies, symptoms traditionally attributed to GERD are difficulty feeding or even feeding refusals, frequent episodes of arching of the back and crying that occur when a child regurgitates, and poor weight gain. In reality, GERD is an uncommon cause of these problems in infants, and many children are diagnosed with GERD simply based on parental descriptions of what the child does and the assumption that their behaviors are a result of pain from acid induced injury to the esophagus.

When babies fail to thrive, typically evident in poor or absent weight gain, GERD should be a diagnosis of exclusion because the most common causes are psychosocial in nature and there are a variety of other medical conditions that need to be ruled out with a thorough history taking, physical exam and targeted diagnostic testing. Respiratory symptoms that are often attributed to GERD include apparent life-threatening events (blue baby, trouble breathing, terrified caregiver), cough, recurrent pneumonia and wheezing. While certainly possible, persistence of these issues requires investigation for other causes, recurrent viral respiratory infections being considerably more common than true GERD in a young infant.

There are a few diagnostic modalities used to evaluate children with suspected GERD or some other condition presenting in a similar fashion. These techniques are infrequently used in infants, however, because of either poor sensitivity and specificity or their invasive nature. We can, using probes placed in the esophagus, quantify the pH and impedance. This can tell us when reflux happens and if it is acidic, but in infants this information doesn’t mean much because apparent symptoms often don’t correlate well with measured reflux events because they usually aren’t caused by the reflux. But this type of investigation can be helpful when a child has the sudden onset of severe symptoms to see if they really do occur at the same time as reflux, although there is still the possibility of a coincidence.

Imaging, specifically what is known as an upper gastrointestinal series, should never be used for routine reflux because it involves a large amount of ionizing radiation and will only reveal what we already know: infants reflux. We don’t need to see it in real time with contrast-laden formula to prove it. This technique is reserved for when there are red flags for an underlying anatomical abnormality. Unfortunately, I still see the occasional perfectly healthy baby who has been diagnosed with reflux using fluoroscopy. Ultrasound imaging of the stomach is also sometimes useful when infants have red flags.

The gold standard in diagnosing GERD, because it allows direct visualization and the ability to take tissue biopsies, is endoscopy. Inserting a scope down the esophagus is usually reserved for when a patient doesn’t respond to less invasive interventions, such as lifestyle modification, medications and dietary changes, and even then it is more about ruling out non-GERD causes of symptoms. It isn’t perfect though. Findings on biopsy do not correlate well with presence or resolution of symptoms in babies.

What is the science-based approach to treating infant reflux/GERD?

To stress again, reassurance is often all that is needed when a baby spits up, and even when there is some concern that they might have mild to moderate GERD. So-called lifestyle modifications are all that is needed in more troublesome cases, even if all that they really do is buy a little time while the reflux resolves on its own. The risks associated with these modifications are very low. If a baby is exposed to cigarette smoke, stop it. Give smaller feeds. Feeds may need to be given a little more frequently or formula can be concentrated to give more calories per ounce, allowing a smaller volume feed. Many babies with reflux are simply overfed, particularly if they are on formula, but this can occur with breastfeeding as well. If breast milk oversupply is a possible issue, lactation experts do have methods of dealing with this.

In general, hopping from formula to formula is not recommended. The differences between competing standard formula brands are clinically meaningless with extremely rare exceptions. But in babies with mild-moderate GERD, many experts recommend an empiric trial of removing cow’s milk from the diet because milk protein allergy is a common GERD mimic. A specialized formula can be used which contains broken down “hypoallergenic” proteins or the mother can attempt to remove dairy from the diet although that can be difficult to achieve and maintain.

Thickening feeds with rice cereal or oatmeal can help, primarily by reducing the number of regurgitation episodes. It likely won’t treat true GERD, however, but it may help change parental perception of symptoms. It isn’t worth it for breastfeeding mothers, as they would need to pump, thicken and feed via a bottle. Thickening significantly increases the caloric density of the formula or breast milk, so weight gain can become an issue. There are also formulas on the market which are “pre-thickened”. They should be of similar effectiveness theoretically but they haven’t been studied enough to say for certain.

Gravity plays a role in causing reflux, and parents can take advantage of it also. Although not well studied, keeping a baby completely upright for 10-20 minutes after each feed is often recommended to reduce reflux episodes. There is no real downside other than the extra time involved. I’ve seen many parents, and a number of medical professionals, who have extrapolated from the likelihood that upright positioning helps to placing a child in, or recommending, partial supine positioning. Sitting in an infant seat actually increases the likelihood of reflux, and achieving a partial incline by placing the child on an elevated mattress might increase the chance of rolling onto a prone position before they are developmentally ready. Prone positioning does decrease reflux but it isn’t worth the increased risk of SIDS.

What about those drugs for reflux/GERD?

As a pediatric hospitalist, I’m hardly shy about throwing evil synthetic pharmaceutical agents at kids. But in the case of reflux and most cases of mild-moderate GERD in infants, they aren’t going to help and will only expose the child to the potential side effects. There are times when they are appropriate, however, such as when endoscopy findings reveal significant inflammation or when there are anatomical/medical conditions that increase the likelihood of GERD. When symptoms are severe and don’t respond to conservative measures, a trial is also reasonable. But they shouldn’t be continued for more than a couple of weeks without clear improvement. Even surgery is sometimes indicated in the most severe cases of GERD, although that is most likely to be required when a child has a neurologic problem that places them at risk of aspirating feeds into the lungs.

As I stated earlier, most babies can’t reliably be diagnosed with GERD because the symptoms are based on parental report for the most part. Parental report can only really be suggestive of GERD. We know that these symptoms almost always respond to lifestyle changes/placebo and regurgitation episodes decrease quickly after 4 months in most infants. There are many studies demonstrating that the conservative approach is best and that medications which decrease or stop acid production often aren’t better than placebo, particularly for the perception of general fussiness.

But these medications are some of the most commonly prescribed in infants, with use of newer (meaning more expensive and more potent) proton pump inhibitors increasing dramatically over the past ten years. This wouldn’t be an issue if they were only prescribed for babies that were more likely to have actual esophageal injury because PPIs are more effective at stopping acid production and allowing the esophagus to heal. They were a game changer in the adult population, where GERD and heartburn are much more easily diagnosed. Many infants are placed on older histamine type 2 receptor blockers, which decrease acid production but don’t stop it. They also have the downside of tachyphylaxis, where a drug loses effectiveness over time, in this case allowing acid production to rebound. They are considerably cheaper though.

What are the risks? Antacids are generally avoided in babies because of the lack of efficacy and risk of toxicity. H2 blockers are pretty safe but lose effectiveness after a few weeks. PPIs are where the real risk is, increasing the likelihood of pneumonia and intestinal infections such as the dreaded Clostridium difficile. Stomach acid plays a role in killing potentially pathogenic bacteria after all. When I was a resident, the drug metoclopramide was all the rage and it used to drive me nuts. It is a prokinetic agent that can enhance emptying of the stomach. Delayed emptying is only rarely a problem in healthy kids and the risks of this medication are considerable, including impressive dystonic muscular contractions and increased risk of seizures.

What about an alternative approach to infant reflux/GERD?

It is a good thing that infant reflux is a generally self-limited and benign condition, although it is often frustrating when excessive parental concern becomes the predominant issue. But most, if not all, pediatricians would much rather work hard to reassure the parent of a well child than have a suffering child. Unfortunately, a combination of many factors frequently lead parents to seek out alternative approaches to infant reflux.

Some parents who bring their baby to a chiropractor because of concerns about reflux, for instance, were going to bring their kid in anyway because it fits into their world view. They will buy unproven herbal concoctions, allow deluded theatrical placebo artists to poke their baby with acupuncture needles, and try just about anything they perceive as a natural remedy. It is unlikely that we are going to have much of an impact on that sad reality.

Certainly some parents are just frustrated by a seeming lack of options with conventional medicine. They may be uncomfortable with giving medications to such a young child. They may just be tired, stressed and online, a combination that probably is to blame for the majority of bad medical decisions. But the children of most parents who seek out natural cures for apparent reflux are also cared for by pediatricians and family doctors. These caregivers are simply seeking out additional help and have been fooled by the pretty wrapping paper on the empty box that is alternative medicine. Maybe we can reach these parents before they take the plunge, wasting money or worse, putting their child’s health at risk.

It isn’t that many proponents of irregular medicine don’t provide some useful information for parents. I’ve spent hours investigating the approach of chiropractors, homeopaths, naturopaths, acupuncturists, etc to reflux and found that we frequently agree. Like me, they tend to stress the benign nature of most cases of reflux and the fact that the attributed symptoms tend to resolve on their own. They talk about the conservative recommendations, and even if the details aren’t always exactly right I didn’t see much of anything that was dangerous. If only they stopped there.

As is always the case, there is little time devoted to educating parents on the nuance of a condition like reflux in a baby. This is likely because nuance is not something that alternative medical practitioners understand themselves. They are more about the big picture. Natural is better. Subluxations are to blame for everything. So forth and so on. They get that reflux is almost always benign but not that the symptoms may not even really exist or may not be caused by reflux. They denigrate drugs because they don’t work but fail to realize that their placebo-based interventions are no different, and they absolutely do not have the training to rule out more concerning conditions that might initially cause symptoms similar to GERD.

A good example I found was a discussion of infant reflux by The Holistic Mama. It contains some good advice, but also a great deal of common bogus concepts like detoxing, essential oils and overzealous elimination diets for breastfeeding mothers. One alternative approach to reflux which was completely new to me was the use of hazelwood reflux jewelry. These are similar to the amber teething necklaces that John Snyder wrote about recently in that they seem to work, defy all plausibility and may serve as a choking hazard.

Chiropractic appears to be the most commonly recommended alternative treatment for infant reflux. The proposed mechanism of action is removing nerve interference cause by subluxations acquired during birth. Despite how easily I found a large number of chiropractic practice websites touting success, Pubmed contained only one published paper on the use of chiropractic for infant reflux, which naturally was a case report. Frequently linked to on said chiropractic websites, this report is another perfect example of why anecdotes usually aren’t helpful for much other than generating a hypothesis. The child in question began chiropractic at exactly the same time that reflux tends to peak and then quickly improve. Also the complaints were subjective and could have easily been affected by a variety of placebo effects.

Conclusion: Reflux in infants is common and usually benign

Gastroesophageal reflux is a common complaint, and affects essentially all young infants. The symptoms related to reflux, the most common being general fussiness, are largely subjective and the connection is not well supported in the literature. It is very likely that in many cases of apparent reflux, parental perception of their child’s symptoms is altered by stress and fatigue.

Despite the knowledge that reflux in babies is a normal aspect of physiology, and almost always benign and self-limited, it has unfortunately become medicalized. This has led to a frequent parental demand for relief from healthcare professionals and the overuse of reflux medications. These medications are unlikely to impact the course of infant reflux beyond the effect of placebo on parental perception of the symptoms, and are not risk free. Rarely is direct and clear evidence of esophageal injury found in an infant, but in some cases a tentative diagnosis of GERD is warranted and a trial of acid-reducing medications indicated. In nearly all cases of reflux in infants, and even with suspected GERD, conservative measures are indicated and should be attempted prior to starting medications.

Because reflux is benign and tends to resolve spontaneously, proponents of unproven alternative medical modalities claim to have both success in curing it and, depending on the type of practice, special knowledge about what causes it. What they do not have is any evidence to support treatment recommendations that aren’t already a component of the conventional approach to management. But even when they give semi-reasonable advice it is often jumbled together with misinformation.